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Original Investigation |

Attention-Deficit/Hyperactivity Disorder Trajectories From Childhood to Young Adulthood Evidence From a Birth Cohort Supporting a Late-Onset Syndrome

Arthur Caye1; Thiago Botter-Maio Rocha, MD, MSc1; Luciana Anselmi, PhD2; Joseph Murray, PhD2,3; Ana M. B. Menezes, PhD2; Fernando C. Barros, PhD2; Helen Gonçalves, PhD2; Fernando Wehrmeister, PhD2; Christina M. Jensen, MSc4; Hans-Christoph Steinhausen, MD, PhD, DMSc4,5,6; James M. Swanson, PhD7; Christian Kieling, MD, PhD1; Luis Augusto Rohde, MD, PhD1,8
[+] Author Affiliations
1ADHD Outpatient Program, Hospital de Clínicas de Porto Alegre, Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
2Post-Graduate Program in Epidemiology, Universidade Federal de Pelotas, Pelotas, Brazil
3Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
4Research Unit for Child and Adolescent Psychiatry, Psychiatric Hospital, Aalborg University Hospital, Aalborg, Denmark
5Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
6Department of Child and Adolescent Psychiatry, University of Zurich, Zurich, Switzerland
7Department of Pediatrics, University of California, Irvine
8National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil
JAMA Psychiatry. 2016;73(7):705-712. doi:10.1001/jamapsychiatry.2016.0383.
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Importance  The requirement of a childhood onset has always been a key criterion for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults, but recently this requirement has become surrounded by controversy.

Objective  To investigate whether impaired young adults with ADHD symptoms always have a childhood-onset disorder in a population-based longitudinal study.

Design, Setting, and Participants  Participants belonged to the 1993 Pelotas Birth Cohort Study, including 5249 individuals born in Pelotas, Brazil, in 1993. They were followed up to 18 to 19 years of age, with 81.3% retention. The data analysis was performed between August 8, 2015, and February 5, 2016.

Main Outcomes and Measures  The ADHD status was first ascertained at 11 years of age using a screening instrument (hyperactivity subscale of the Strength and Difficulties Questionnaire) calibrated for a DSM-IV ADHD diagnosis based on clinical interviews with parents using the Development and Well-Being Assessment. At 18 to 19 years of age, ADHD diagnosis was derived using DSM-5 criteria, except age at onset. We estimated the overlap between these groups assessed at 11 and 18 to 19 years of age and the rates of markers of impairment in these 2 groups compared with those without ADHD.

Results  At 11 years of age, childhood ADHD (C-ADHD) was present in 393 individuals (8.9%). At 18 to 19 years of age, 492 individuals (12.2%) fulfilled all DSM-5 criteria for young adult ADHD (YA-ADHD), except age at onset. After comorbidities were excluded, the prevalence of YA-ADHD without comorbidities decreased to 256 individuals (6.3%). Children with C-ADHD had a male preponderance not observed among children without ADHD (251 [63.9%] vs 1930 [47.9%] male, P < .001), whereas the YA-ADHD group had a female preponderance (192 [39.0%] vs 1786 [50.4%] male, P < .001). Both groups had increased levels of impairment in adulthood, as measured by traffic incidents, criminal behavior, incarceration, suicide attempts, and comorbidities. However, only 60 children (17.2%) with ADHD continued to have ADHD as young adults, and only 60 young adults (12.6%) with ADHD had the disorder in childhood.

Conclusions and Relevance  The findings of this study do not support the assumption that adulthood ADHD is necessarily a continuation of childhood ADHD. Rather, they suggest the existence of 2 syndromes that have distinct developmental trajectories.

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Figure 1.
Follow-Forward and Follow-Back Analyses of Individuals With Attention-Deficit/Hyperactivity Disorder (ADHD)

C-ADHD indicates childhood attention-deficit/hyperactivity disorder; YA-ADHD, young adult attention-deficit/hyperactivity disorder; YA-ADHD-WC, young adult attention-deficit/hyperactivity disorder without comorbidities.

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Figure 2.
Number of Young Adult Attention-Deficit/Hyperactivity Disorder (YA-ADHD) Symptoms in the Childhood Attention-Deficit/Hyperactivity Disorder (C-ADHD), YA-ADHD, and Young Adult Attention-Deficit/Hyperactivity Disorder Without Comorbidities (YA-ADHD-WC) Groups
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